Rural Stroke Care: How EMS Changed Overnight

March 30, 2022 by Ellen Brennan

In 2018, the timeline for a life-saving stroke treatment was extended from 6 hours to 24 hours after stroke. That changed the landscape of stroke care, and the story is how EMS responded. Read this highlight to learn how one pilot project turned into a tri-state partnership and policy change that revolutionized how emergency personnel respond to stroke in the field.

Emergency Medical Services in Vermont, Maine, and New Hampshire have joined forces to revolutionize how EMTs respond to stroke in the field. But to truly appreciate the significance of their work, we first must understand the history of stroke care.

“When I tell the story, I start with the true story,” says Dr. Daniel Wolfson, Vermont State EMS Medical Director and emergency medicine physician at UVM Medical Center. “When I was a kid, my grandfather had a stroke. It was one of the really bad strokes that left you pretty debilitated, and there was nothing you could do for it. Those folks got put in a hallway somewhere, eventually just put up in a bed in the hospital. There was really no treatment. Then they came out with tPA.”

TPA is a drug given intravenously that can help remove or dissolve blood clots, but it has to be administered within 3.5-4.5 hours after stroke onset to have any chance of efficacy.

“So now there’s this small little window of treatment when you could potentially use tPA and reverse stroke symptoms, but it was just so short. … Then they came out with thrombectomy, and now if you’ve missed that tPA window, you could go in and mechanically retrieve the clot.” ~ Dan

Thrombectomies are highly effective surgical procedures where the clot is physically removed from the larger blood vessels in the brain, dramatically reversing symptoms in cases that would have previously been some of the most severe types of strokes. “So there’s some light at the end of the tunnel,” Dan continues, “but that used to only be good for up to six hours.”

“But then, in 2018 when the New England Journal published a couple articles on extending thrombectomy to 24 hours, that was it. That changed the landscape of stroke care, and the story is how EMS responded.” ~ Dan

Dan says that with this new 24-hour window, the job of EMS had to change overnight. “Before, we would call a stroke alert, and that would alert the hospital that we were bringing in a suspected stroke patient. And then we felt like our job from the EMS side of things, the pre-hospital setting, was done.” However, when the new guidelines came out, it became clear that identifying the severity of the stroke as soon as possible was critical, but there were two important considerations.

First, thrombectomies are only used when patients have passed that 3-4 hour deadline for tPA and have a high stroke severity score, meaning patients with less severe types of strokes wouldn’t qualify for this procedure. “There’s no reason to divert to a stroke center if you can still get tPA nearby or if you’re not going to qualify,” Dan explained. “It’s much better to keep those patients closer to home.”

Second, only a handful of hospitals in the entire northern New England region offer thrombectomies, and with so many of our communities located in rural areas, that means patients were often unable to be transported to these few and far between centers in time. With this new 24-hour window, it was suddenly possible to make that happen. Taken together, it was clear that stroke severity needed to be measured early, and that means doing so in the field.

To meet this new opportunity for better stroke care, Dan began a pilot project with the NNE-CTR aimed at testing whether an app could help rural EMTs effectively calculate the FAST-ED score, a score that measures the stroke’s severity right there in the field. The JoinTriage app, developed by ALLM, Inc., takes information supplied by the responding EMT and calculates the FAST-ED stroke severity score, identifies the nearest medical center offering the treatment best suited for that individual patient, and provides the route from their location to that center. Dan and his team set out to educate every EMS agency in the state of Vermont in the use of the app and collect data on whether the app’s calculated score in the field matched the score calculated at the hospital. The hope was that through training rural EMS personnel in the use of this tool, they could provide more equitable stroke care even in our remote areas that experience geographical barriers to accessing treatment.

But they didn’t stop there. Leveraging the resources provided by the NNE-CTR, Dan helped cultivate a team across Vermont, Maine, and New Hampshire that included all three State EMS Medical Directors, emergency physicians and neurologists at each thrombectomy-providing hospital, research technicians, and project managers. Together, they were able to add FAST-ED training to the official protocols for EMS education and procedures, and now all three states calculate the FAST-ED score in the field. Now, this large team is creating the first research consortium focused on a rural region, collecting data on the scores, response times, patient outcomes, and so much more to analyze exactly how they can provide the best care for stroke patients in all of our rural and urban communities.

“Northern New England, we’re a pretty unique place,” says Dan. “We’re largely rural and widespread. This was an amazing opportunity for us to collaborate with our other northern New England partners and do something like this. What we’ve set up, we hope will lead to research on other rural EMS questions. So. That’s a pretty good story.” ~ Dan